Medicare Coverage / Risk Adjustment Quiz

The Medicare program has many rules and regulations. This quiz will cover some of the more common information about general Medicare coverage and the Risk Adjustment Program.

Medicare Coverage / Risk Adjustment Quiz

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This quiz will evaluate your knowledge of Medicare Coverage. There is one correct answer for each question and no time limit on this quiz.
Each correct answer is worth one point. Good luck.
Disclaimer - All answers are felt to be correct. However, if you disagree, please research the issue. Mistakes happen.
This quiz has been reviewed and approved by Health Information Professionals who serve as HITNOTS Reviewers.
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Question 1

This type of service would be provided to an outpatient Medicare patient by a non-physician practitioner. The supervising physician, however, must be present in the office and supervise the non-physician practitioner. This type of service can be billed to Medicare as:

A

Incident to service

B

Medigap

C

Fee for service

D

Part A Medicare

Question 1 Explanation:

Source - www.Medicare.gov

Question 2

This is a CMS payment method which provides a risk factor score for Medicare Advantage patients with chronic illness. This score reflects patient complexity and is used to calculate and adjust payments to providers.

A

Fee for service

B

Risk Adjustment

C

Diagnosis Related Groups

D

Capitation

Question 3

Medicare's Hierarchical Condition Categories (HCC) model is based upon which coding system?

A

CPT®

B

ICD-10-PCS

C

ICD-10-CM

D

HCPCS

Question 4

In the Risk Adjustment program from CMS, it is possible for two different patients within the same geographic community to have different payment rates.

A

No

B

Yes

Question 4 Explanation:

The payment rate is based the amount of risk, or medical intervention, it will take to maintain the individual patient's health. For example, a patient with a chronic illness, such as diabetes, will likely take more medical intervention, than another patient without any chronic illness.

Question 5

To be eligible for Medicare Part A and B, you must:

A

be a US citizen or permanent legal resident for at least five years.

B

have been employed under Social Security.

C

have been born in the United States.

Question 6

Most of the Medicare Prescription Drug Plans have a gap in coverage . This means there's a temporary limit on what the drug plan will cover for drugs. This temporary gap in prescription drug coverage is called:

A

out of pocket costs

B

Medicare Part D

C

the donut hole

D

Medigap

Question 7

Medicare's Risk Adjustment model is one that uses reported diagnoses in the current year to predict healthcare expenditures in the following year. This type of model is called:

A

prospective

B

archived

C

retrospective

D

concurrent

Question 8

According to CMS, by using the Risk Adjustment Program, CMS is able to make appropriate and accurate payments for Medicare Advantage enrollees who have differences in:

A

expected costs.

B

occupations.

C

age.

D

geographic locations.

Question 8 Explanation:

The "expected costs" are based upon the patient's risk. Patients with more serious and chronic diagnoses are more at risk than those without.

Question 9

In Medicare's Risk Adjustment program (RA), a patient's chronic conditions should be reported ________.

Assume that William, age 70 visited the Emergency Department (ED) and spent one day getting observation services. Then, William was formally admitted to the hospital as an inpatient for 2 more days, then discharged. Assuming that William needs skilled nursing care, will William's SNF stay be covered by Medicare?

No. Even though William spent 3 days in the hospital, he was considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Assume that an 84 year old patient (Joan) went to the Emergency Department (ED) and was formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. Joan was discharged on the 4th day. Assuming that she needs skilled nursing care, will her skilled nursing facility (SNF) stay be covered by Medicare?

In Medicare's Risk Adjustment program, risk adjustment scores are ______ for a patient with a greater disease burden.

A

higher

B

lower

Question 24

All of the following except ____ are NOT covered by Medicare Part A or B.

A

cosmetic surgery

B

hearing aids

C

long term custodial care

D

doctor office visit

Question 25

With this type of Medicare fraud, the medical provider bills Medicare for unnecessary procedures, or procedures that are never performed; for unnecessary medical tests or tests never performed; for unnecessary equipment; or equipment that is billed as new but is, in fact, used.

A

Upcoding

B

Phantom billing

C

Unbundling

D

Patient billing

Question 25 Explanation:

Source - https://en.wikipedia.org/wiki/Medicare_fraud

Question 26

The Risk Adjustment (RA) program from Medicare is based on all of the following demographics except:

A

age

B

occupation

C

sex

D

health status

Question 27

Lab tests, surgery, and x-rays that take place for a hospital inpatient are covered by:

A

Part C Medicare

B

Part D Medicare

C

Part A Medicare

D

Part B Medicare

Question 28

This type of claim occurs when the claim cannot be processed due to technical errors, invalid, or missing info, or claim submission instructions not being followed.

A

Rejected claim

B

Dirty claim

C

Clean claim

D

Pending claim

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